HIV incidence remains high in KwaZulu-Natal, South Africa: evidence from three districts

Background

HIV prevalence and incidence among sexually active women in peri-urban areas of Ladysmith, Edendale, and Pinetown, KwaZulu-Natal, South Africa, were assessed between October 2007 and February 2010 in preparation for vaginal microbicide trials.

Methodology/Principal Findings

Sexually active women 18–35 years, not known to be HIV-positive or pregnant were tested cross-sectionally to determine HIV and pregnancy prevalence (798 in Ladysmith, 1,084 in Edendale, and 891 in Pinetown). Out of these, approximately 300 confirmed non-pregnant, HIV-negative women were subsequently enrolled at each clinical research center (CRC) in a 12-month cohort study with quarterly study visits. Women in the cohort studies were required to use a condom plus a hormonal contraceptive method. HIV prevalence rates in the baseline cross-sectional surveys were high: 42% in Ladysmith, 46% in Edendale and 41% in Pinetown. Around 90% of study participants at each CRC reported one sex partner in the last 3 months, but only 14–30% stated that they were sure that none of their sex partners were HIV-positive. HIV incidence rates based on seroconversions over 12 months were 14.8/100 person-years (PY) (95% CI 9.7, 19.8) in Ladysmith, 6.3/100 PY (95% CI 3.2, 9.4) in Edendale, and 7.2/100 PY (95% CI 3.7, 10.7) in Pinetown. The 12-month pregnancy incidence rates (in the context of high reported contraceptive use) were: 5.7/100 PY (95% CI 2.6, 8.7) in Ladysmith, 3.1/100 PY (95% CI 0.9, 5.2) in Edendale and 6.3/100 PY (95% CI 3.0, 9.6) in Pinetown.

Conclusions/Significance

HIV prevalence and incidence remain high in peri-urban areas of KwaZulu-Natal.     

The Impact of Gender Norms on Condom Use among HIV-Positive Adults in KwaZulu-Natal,South Africa

Critical to preventing the spread of HIV is promoting condom use among HIV-positive individuals. Previous studies suggest that gender norms (social and cultural constructions of the ways that women and men are expected to behave) may be an important determinant of condom use. However, the relationship has not been evaluated among HIV-positive women and men in South Africa. We examined gender norms and condom use at last sex among 550 partnerships reported by 530 sexually-active HIV-positive women (372) and men (158) who had sought care, but not yet initiated antiretroviral therapy in a high HIV-prevalence rural setting in KwaZulu-Natal, South Africa between January 2009 and March 2011. Participants enrolled in the cohort study completed a baseline questionnaire that detailed their socio-demographic characteristics, socio-economic circumstances, religion, HIV testing history and disclosure of HIV status, stigma, social capital, gender norms and self-efficacy. Gender norms did not statistically differ between women and men (p = 0.18). Overall, condoms were used at last sex in 58% of partnerships. Although participants disclosed their HIV status in 66% of the partnerships, 60% did not have knowledge of their partner’s HIV status. In multivariable logistic regression, run separately for each sex, women younger than 26 years with more equitable gender norms were significantly more likely to have used a condom at last sex than those of the same age group with inequitable gender norms (OR = 8.88, 95% CI 2.95–26.75); the association between condom use and gender norms among women aged 26+ years and men of all ages was not statistically significant. Strategies to address gender inequity should be integrated into positive prevention interventions, particularly for younger women, and supported by efforts at a societal level to decrease gender inequality.     

Treatment of Cryptococcal Meningitis in KwaZulu-Natal,South Africa

Background

Cryptococcal meningitis (CM) remains a leading cause of death for HIV-infected individuals in sub-Saharan Africa. Improved treatment strategies are needed if individuals are to benefit from the increasing availability of antiretroviral therapy. We investigated the factors associated with mortality in routine care in KwaZulu-Natal, South Africa.

Methodology/Principal Findings

A prospective year long, single-center, consecutive case series of individuals diagnosed with cryptococcal meningitis 190 patients were diagnosed with culture positive cryptococcal meningitis, of whom 186 were included in the study. 52/186 (28.0%) patients died within 14 days of diagnosis and 60/186 (32.3%) had died by day 28. In multivariable cox regression analysis, focal neurology (aHR 11 95%C.I. 3.08–39.3, P<0.001), diastolic blood pressure <60 mmHg (aHR 2.37 95%C.I. 1.11–5.04, P = 0.025), concurrent treatment for tuberculosis (aHR 2.11 95%C.I. 1.02–4.35, P = 0.044) and use of fluconazole monotherapy (aHR 3.69 95% C.I. 1.74–7.85, P<0.001) were associated with increased mortality at 14 and 28 days.

Conclusions

Even in a setting where amphotericin B is available, mortality from cryptococcal meningitis in this setting is high, particularly in the immediate period after diagnosis. This highlights the still unmet need not only for earlier diagnosis of HIV and timely access to treatment of opportunistic infections, but for better treatment strategies of cryptococcal meningitis.     

Spread of extensively drug-resistant tuberculosis in KwaZulu-Natal province, South Africa

Background

In 2005 a cluster of 53 HIV-infected patients with extensively drug-resistant tuberculosis (XDR-TB) was detected in the Msinga sub-district, the catchment area for the Church of Scotland Hospital (CoSH) in Tugela Ferry, in KwaZulu-Natal province (KZN), South Africa. KZN is divided into 11 healthcare districts. We sought to determine the distribution of XDR TB cases in the province in relation to population density.

Methods

In this cross-sectional study, the KZN tuberculosis laboratory database was analysed. Results of all patients with a sputum culture positive for Mycobacterium tuberculosis from January 2006 to June 2007 were included. Drug-susceptibility test results for isoniazid, rifampicin, ethambutol, streptomycin, kanamycin and ofloxacin were available for all patients as well as the location of the hospital where their clinical diagnosis was made.

Findings

In total, 20858 patients attending one of 73 hospitals or their adjacent clinics had cultures positive for M. tuberculosis. Of these, 4170 (20%) were MDR-TB cases. Four hundred and forty three (11%) of the MDR tuberculosis cases displayed the XDR tuberculosis susceptibility profile. Only 1429 (34%) of the MDR-TB patients were seen at the provincial referral hospital for treatment. The proportion of XDR-TB amongst culture-confirmed cases was highest in the Msinga sub-district (19.6%), followed by the remaining part of the Umzinyati district (5.9%) and the other 10 districts (1.1%). The number of hospitals with at least one XDR-TB case increased from 18 (25%) to 58 (80%) during the study period.

Interpretation

XDR-TB is present throughout KZN. More than 65% of all diagnosed MDR-TB cases, including XDR-TB patients, were left untreated and likely remained in the community as a source of infection.     

Participation Dynamics in Population-Based Longitudinal HIV Surveillance in Rural South Africa

Population-based HIV surveillance is crucial to inform understanding of the HIV pandemic and evaluate HIV interventions, but little is known about longitudinal participation patterns in such settings. We investigated the dynamics of longitudinal participation patterns in a high HIV prevalence surveillance setting in rural South Africa between 2003 and 2012, taking into account demographic dynamics. At any given survey round, 22,708 to 30,495 persons were eligible. Although the yearly participation rates were relatively modest (26% to 46%), cumulative rates increased substantially with multiple recruitment opportunities: 68% of eligible persons participated at least once, 48% at least twice and 31% at least three times after five survey rounds. We identified two types of study fatigue: at the individual level, contact and consent rates decreased with multiple recruitment opportunities and, at the population level, these rates also decreased over calendar time, independently of multiple recruitment opportunities. Using sequence analysis and hierarchical clustering, we identified three broad individual participation profiles: consenters (20%), switchers (43%) and refusers (37%). Men were over represented among refusers, women among consenters, and temporary non-residents among switchers. The specific subgroup of persons who were systemically not contacted or refusers constitutes a challenge for population-based surveillance and interventions.     

Dietary Adequacies among South African Adults in Rural KwaZulu-Natal

Background

Food quality, determined by micronutrient content, is a stronger determinant of nutritional status than food quantity. Health concerns resulting from the co-existence of over-nutrition and under-nutrition in low income populations in South Africa have been fully recognized in the last two decades. This study aimed to further investigate dietary adequacy amongst adults in rural KwaZulu-Natal, by determining daily energy and nutrient intakes, and identifying the degree of satisfaction of dietary requirements.

Methods

Cross-sectional study assessing dietary adequacy from 24-hour dietary recalls of randomly selected 136 adults in Empangeni, KwaZulu-Natal, South Africa.

Results

Results are presented for men (n = 52) and women (n = 84) 19–50 and >50 years old. Mean energy intake was greatest in women >50 years (2852 kcal/day) and exceeded Dietary Reference Intake’s for both men and women, regardless of age. Mean daily energy intake from carbohydrates was 69% for men and 67% for women, above the Dietary Reference Intake range of 45–65%. Sodium was also consumed in excess, and the Dietary Reference Intakes of vitamins A, B12, C, D, and E, calcium, zinc and pantothenic acid were not met by the majority of the population.

Conclusion

Despite mandatory fortification of staple South African foods, micronutrient inadequacies are evident among adults in rural South African communities. Given the excess caloric intake and the rising prevalence of obesity and other non-communicable diseases in South Africa, a focus on diet quality may be a more effective approach to influence micronutrient status than a focus on diet quantity.     

Characterizing the Late Pleistocene MSA Lithic Technology of Sibudu,KwaZulu-Natal,South Africa

Studies of the African Middle Stone Age (MSA) have become central for defining the cultural adaptations that accompanied the evolution of modern humans. While much of recent research in South Africa has focused on the Still Bay and Howiesons Poort (HP), periods following these technocomplexes were often neglected. Here we examine lithic assemblages from Sibudu that post-date the HP to further the understanding of MSA cultural variability during the Late Pleistocene. Sibudu preserves an exceptionally thick, rich, and high-resolution archaeological sequence that dates to ∼58 ka, which has recently been proposed as type assemblage for the “Sibudan”. This study presents a detailed analysis of the six uppermost lithic assemblages from these deposits (BM-BSP) that we excavated from 2011–2013. We define the key elements of the lithic technology and compare our findings to other assemblages post-dating the HP. The six lithic assemblages provide a distinct and robust cultural signal, closely resembling each other in various technological, techno-functional, techno-economic, and typological characteristics. These results refute assertions that modern humans living after the HP possessed an unstructured and unsophisticated MSA lithic technology. While we observed several parallels with other contemporaneous MSA sites, particularly in the eastern part of southern Africa, the lithic assemblages at Sibudu demonstrate a distinct and so far unique combination of techno-typological traits. Our findings support the use of the Sibudan to help structuring this part of the southern African MSA and emphasize the need for further research to identify the spatial and temporal extent of this proposed cultural unit.     

Release of rehabilitated Chlorocebus aethiops to Isishlengeni Game Farm in KwaZulu-Natal,South Africa

Chlorocebus aethiops are treated as vermin by some in South Africa, and this has resulted in injury, illness and death of hundreds of C. aethiops, with orphans being very common. Rehabilitation centres care for, rehabilitate and aim to return these monkeys to the wild. This study describes the release of 29 C. aethiops to Isishlengeni Game Farm in KwaZulu-Natal, South Africa. The troop was monitored for six months. Confirmed survival of the troop was 62%, with 17% suspected mortality and 21% of the troop unaccounted for. The release site was not ideal due to hunting activities, the proximity of dwellings and roads and the presence of a wild troop. Preparation for release could be improved through the provision of naturally occurring foods and pre-release disease screening. Post-release monitoring would greatly benefit from the use of tracking devices to allow all animals to be followed post-release.     

Vegetation variation within and among palustrine wetlands along an altitudinal gradient in KwaZulu-Natal,South Africa

The variation in graminoid species composition and diversity and the distribution of photosynthetic pathways among 66 wetlands in KwaZulu-Natal, South Africa, and within six of these wetlands was described and related to measured physical parameters, using multivariate and univariate techniques. Altitude, which ranged from 550 m to 2120 m, accounted for most variation among wetlands, with an almost complete turnover of species along this gradient. Landform setting was less important in explaining overall species composition, but relationships of individual species were revealed (e.g. Eleocharis dregeana showed an affinity for depressions). Within a wetland there was an almost complete turnover of species along a gradient of wetness, as described using soil morphological criteria. Most species were consistently associated with the same wetness zones across different wetland sites, e.g., Phragmites australis with the wettest zone, Pycreus macranthus with the intermediate zone, and Eragrostis plana with the least wet zone. The occurrence and abundance of different photosynthetic pathway types depended on altitude and degree of wetness. At high altitudes, C₃ sedges, notably Carex acutiformis, dominated the wettest zone and C₃ and C₄ grasses and sedges dominated the intermediate and least wet zones. At mid altitudes, C₃ and C₄ sedges and C₃ grasses dominated the wettest zone, C₃ and C₄ grasses and sedges dominated the intermediate zone and C₄ grasses dominated the least wet zone. Low altitude sites showed a similar distribution of photosynthetic pathways as mid-altitude sites, but C₃ species were less abundant. Species richness was positively associated with the log of wetland size and, at the level of an individual wetland, species richness and evenness were found to be consistently greater in the intermediate and least wet zone compared with the wettest zone. The management implications of the results are discussed in the light of continuing anthropogenic loss of wetlands in the study area and global climate change.     

Knowledge,Practices, and Attitudes of Emergency Contraception among Female University Students in KwaZulu-Natal,South Africa

Objective

The purpose of this study is to investigate the knowledge, practices, and attitudes among female university students in South Africa regarding emergency contraceptives (EC).

Methods

A cross-sectional study was conducted among 582 female university students who were selected using multi-stage sampling techniques. Multivariate logistic regression analysis was used to find significant predictors for EC awareness.

Results

The average age of the female students was 20.9 years (SD = 3.0) and 57.2% were presently sexually active. Overall, 49.8% of the participants reported having heard about EC prior to the study. Regarding sexual activities among the female students, 53.2% reported to have sex, and 21.2% of the sexually experienced students used EC prior to the study. Regarding the effectiveness of EC, 29.5% students said it could be used up to 72 hours after unprotected sexual intercourse, and 8% said it could be used just before sex. About two-thirds (61.8%) would recommend the use of EC and 63.2% would use it if they needed. The multivariate analysis indicated that students who were older (>20 years), presently sexually active, and living with their parents were more likely to be aware of EC (p<0.05).

Conclusion

The students’ knowledge and utilization of EC were low. Health education and promotion should be targeted towards these students, and the EC services should be offered on campus.     

Soil Characteristics of Rehabilitating and Unmined Coastal Dunes at Richards Bay, KwaZulu-Natal, South Africa

The postmining rehabilitation of coastal sand dunes north of Richards Bay (28°43′S, 32°12′E), South Africa, is resulting in the development of a series of known-aged stands of vegetation dominated by Acacia karroo (sweet thorn). Other broad-leaved species are establishing themselves in rehabilitating areas more than 12 years of age. Soils from rehabilitating stands 3–5, 9–12, 13–15, and 16–18 years of age, from two disturbed, unmined stands 30 and 58 years of age, and from a mature unmined stand were examined to assess age-related trends in selected soil properties. Individually, these stands represent a series of different developmental stages of a coastal dune successional sere. Soil organic material, percentage organic carbon and concentrations of sodium, potassium, magnesium, calcium, and nitrogen increased with an increase in habitat regeneration age. Concentrations of most of these elements were lower than those recorded on the 58-year-old unmined and mature unmined stands. Multivariate analyses suggest, however, that the similarity of these values for rehabilitating stands to those for the unmined stands increased with an increase in regeneration age. The growth response of Raphanus sativus (radish) plants, based on mass attained under experimental growing conditions in soil collected from these stands, suggests an increase in soil fertility with an increase in regeneration age.     

Association between Health Systems Performance and Treatment Outcomes in Patients Co-Infected with MDR-TB and HIV in KwaZulu-Natal,South Africa: Implications for TB Programmes

Objective

To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites.

Methods

In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings.

Findings

We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the ‘integration’ domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the ‘context’ domain influenced the other domains.

Conclusion

We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.     

A Holocene sequence of vegetation change at Lake Eteza, coastal KwaZulu-Natal, South Africa

Palynological and sedimentological data from a core extracted from Lake Eteza shed new light on the Holocene vegetation and climate history in KwaZulu-Natal and can be linked to regional and global climate change. A 2072 cm core with nineteen radiocarbon dates and chronological extrapolation to the bottom of the sequence suggests that sedimentation started ca. 10 200 cal yrs BP. Between ca. 10 200 and 6800 cal yrs BP pollen indicators point to a change from intermediately humid conditions to comparatively drier grassy environments. This is in good agreement with Sea Surface Temperature (SST) fluctuations from a core in the Mozambique Channel which influence precipitation in coastal KwaZulu-Natal, and the beginning of the Holocene Thermal Maximum ca. 10 500 cal yrs BP. The lower section of the core corresponds to gradually increasing Holocene sea levels along the coast and development of freshwater or estuarine conditions at Lake Eteza. The middle Holocene (ca. 6800-3600 cal yrs BP), when the sea level reached its highest stand and SST peak, indicate humid climatic conditions that favoured an increase of forest trees, e.g. Podocarpus, and undergrowth plants like Issoglossa. As a consequence of higher precipitation and increase of the water table, conditions were favourable for the spread of mangrove, swamp and possibly riverine forest. During the late Holocene after ca. 3600 cal yrs BP a decrease of Podocarpus and other trees as well as an increase of Chenopodiaceae/Amaranthaceae, grasses and Phoenix coincide with a return to lower sea levels and drier conditions. The decrease of all trees including Phoenix at ca. 700 cal yrs BP, accompanied by rapid sedimentation rates, possibly reflect forest clearing and upland erosion induced by activities of Iron Age settlers. A dry period at the globally recognized onset of the Little Ice Age might have contributed to these changes. Late Iron Age settlers have probably already introduced Zea mays, which was detected in the profile since ca. 210 BP. The appearance of neophytes like Pinus, Casuarina and pollen of Ambrosia-type in the youngest sediments indicates increased disturbance of European settlements and land use since ca. 100 cal yrs BP.